Dermatology Symposium October 21, 2018 Elmwood Zoo Norristown, PA
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Dermatology Symposium October 21, 2018 Elmwood Zoo Norristown, PA
DERMATOLOGY SYMPOSIUM AGENDA
9:00am-9:30am- Breakfast & Registration Opens
9:30am-9:40am- Welcome & Introductions
9:40am-10:40am- Atopic Dermatitis: 21st-century medicine for 21st-century dogs- Dr. Valerie Fadok
10:40am-10:50am- AM Break (10 minutes)
10:50am-11:50pm- 2018 Practical Dermatology Updates - What's New Besides Donald and Royal
Weddings? - Dr. Brian Palmeiro
11:50am-12:50pm Lunch (1 hour)
12:50pm- 1:50pm- Managing Pyoderma is not what it used to be- Dr. Valerie Fadok
1:50pm- 2:00pm- PM Break (10 minutes)
2:00pm- 3:00pm- Food Allergy—Love it or Hate it? -Dr. Kevin Shanley
3:00pm Event Closing Remarks
Thank you to our 2018 Sponsors!
We are only able to provide this CE program FREE of charge due to the support of our sponsors. Please
make sure to visit their tables and thank them for helping to bring CE programming to the veterinary
community.
10/19/18
Atopic Dermatitis
21st century medicine for 21st century dogs
Valerie A. Fadok, DVM, PhD, Diplomate ACVD
1| valerie.fadok@zoetis.com
Do you know how many itchy dogs see
veterinarians in the USA?
Rest have
preventable
About 8 disease with
million! About half of short term
these have need for itch
chronic control
atopic
dermatitis
Data acquired from VetStreet
2|
ALLERGENS ASSOCIATED WITH
ATOPIC DERMATITIS
1
10/19/18
Allergens to consider
ÊPollens
ÊGreer Laboratories website L
ÊPollen.com
4|
Pollen.com
5|
ÊMites
Allergens to consider
ÊHouse dust mites
ÊPollens ÊStorage mites
ÊGreer Laboratories website L ÊInsects
ÊPollen.com ÊCockroach
ÊMolds ÊAnts
ÊMore important in some regions than ÊBiting insects
others
ÊFoods
ÊDanders
ÊMicrobial allergens
Ê30% of my dogs and cats are allergic
to human dander ÊStaphylococcus
ÊAtopic dogs that live with cats can be ÊMalassezia
6|
allergic to cats and vice versa
2
10/19/18
PATHOGENESIS
What do we know about allergic itch and
inflammation?
Imbalanced
immune system Th1
Th2
Allergic cytokines
Itch and
inflammation
8|
30 years of basic and translational research . . .
• More to atopic dermatitis than IgE
• HOWEVER a role for IgE maintained
• Skin barrier defects
• T cell subsets and cytokines
• Dendritic cell subsets and cytokines
• Signal transduction mechanisms
• Janus kinases
9|
3
10/19/18
8
The Immune Response, T Helper Style
T helper 1 T helper 2 T helper 17
IL-4
IL-17
IL-2 IL-5
IL-21
IFNg IL-6
IL-22
TNFa IL-10
Il-13 IL-26
TNFb/LT
IL-31 (GM-CSF, TNFa)
Protect against IC
Promote antibody
pathogens Protect surfaces
production
(e.g viruses)
Protect against
Allergy
Protect against
against extracellular
pathogens
parasites
tumors
10 |
11
Tissue Environment Influences T Cell Education
Normal Allergic
Tissue Tissue
DC1 DC2
Th1 Th2
11 |
The disease starts with transepidermal absorption of allergens
through an epidermis that has a defective barrier function
Water
R Weeks
12 |
4
10/19/18
Allergic DC
T helper 2 cells
home to the skin
13 |
Adapted from: Bieber, NEJM 358:1483, 2008
Environment Modified from Bieber and Novak, 2009
Current Allergy Asthma Rep 9:291.
E nvironm ental S cratching,
A llergens Staphylococcus
Factors Tissue dam age
N onatopic S ensitization A topic S ensitization A utoallergic
derm atitis to allergens derm atitis to self proteins A topic derm atitis
Im paired R eceptors,
epithelial barrier C ytokines, etc.
Tissue genes Im m une genes
Genes
14 |
Progression to Chronic Disease
The Cycle of Itch & Inflammation
15 |
5
10/19/18
ATOPIC DERMATITIS: A
DIAGNOSIS OF EXCLUSION
FIRST STOP THE ITCH
PROTECTING THE BONDS THAT MATTER MOST
17 |
Then the diagnostic workup
Rule-out / Treat Potentially Curable Underlying Causes First
Easier to Tx
1 Parasites
2 Pyoderma, yeast infection
3 Food allergy
4 Atopic dermatitis
Harder to Tx
Michele Rosenbaum, Zoetis
18
6
10/19/18
New Tools To Share with Clients!
19 |
Occurs in dogs < 3 yrs
Itch without lesions occurs first
Feet and ears affected
20 |
Breeds of predisposition
1460 snorts and snores
110 medicated baths
48 killed squeaky toys
2 intimidated big dogs
1 Dobby
Treatment of atopic dermatitis
Commit to excellent itch control
7
10/19/18
What do clients really want?
COMMUNICATION: TREATMENT:
RELATIONSHIP-CENTERED EFFECTIVE AND SAFE
options explained • Anchor treatment: (single therapy -
to be part of decision-making satisfactory control - sustainable)
– APOQUEL®, CYTOPOINT®
(partners)
– Cyclosporine, ASIT
To understand value of treatment to
• Adjunctive
pet’s well-being
– Skin hygiene/barrier repair
Can We Identify and Strengthen the – Flea control (ALWAYS in the Fadok
Bonds Throughout This Process? arsenal
– Avoid flare factors
22 |
The multimodal approach to atopic dermatitis
Individualized for each dog
1. Control itch and inflammation
5. ASIT (injection, SLIT 2. Avoidance (fleas, foods)
4. Repair the barrier 3. Control infections
23 |
23
Itch Control Over The Decades
Glucocorticoids
Cyclosporine (Atopica®)
Oclacitinib (Apoquel®)
Atopica ® is registered tradem ark of Eli Lilly and C om pany, Cytopoint®
its subsidiaries and affiliates.
24 |
810/19/18
Glucocorticoids: The atom bomb of inflammation control
25 |
Cyclosporine: 1st step on the path to targeted treatment
• T lymphocytes
• DC and
macrophages
• NK cells
• Keratinocytes
• Others
• IL-2 and IL-2R
• IL-4
• IL-1b
• IL-6
• TNFa
• IL-8
• Also IL-3, GM-
CSF, PgE2
26 |
C yto kin e bin ds receptor IL-31 cytokine
IL-13 IL-4
IL-2
IL-6
IL-31
C Y TO P O IN T
APOQUEL
JA K neutralizes
binds JA K
only
and w orks
Blocked IL-31 cytokine
after
before binding
Pathw ays cytokines
Dow nstream to receptor
bind to
receptor signaling is
not triggered
27 |
910/19/18
Allergic Sola has a hot spot
28 |
Perspectives: Through the Eye of the Beholder
Sola
Life with dogs:
The day I thought my dog was dying
http://www.lifewithdogs.tv/2011/08/the-day-i-thought-my-dog-was-dying/
29 |
Quotes from the blog
“We narrowed the
list to two: an ultra
toxic spider bite, or
“Itlooked like she some exotic flesh-
had been mauled eating bacteria.”
by a bear.”
“I was thoroughly
unprepared for the
waft of rotten air “my thoughts
that was propelled consumed with my
my way with each beloved dog and
stroke of that paw.” the fear of losing
her.”
30 |
1010/19/18
Why Start With Apoquel? Vet reasons
Antihistamines
Don’t work
Owners have tried them
Inhibit workup
31 |
31
Why Start With Apoquel? Vet reasons
Antihistamines
Don’t work
Owners have tried them
Inhibit workup
Steroids
Short term side effects are not rare
They mask efficacy of antibiotics.
May worsen the skin barrier defect
Inhibit work up
Indirect cost
32 |
32
Why Start With Apoquel? Vet reasons
Antihistamines Apoquel
Don’t work APPROVED FOR ITCH RELIEF IN
ANY ALLERGIC CONDITION AND
Owners have tried them IT WORKS!
Inhibit workup Won’t inhibit workup
Steroids
Will NOT mask efficacy (or lack
Short term side effects are not rare there of) of antibiotics for pyoderma
They mask efficacy of antibiotics. – If not 50% better in 2 weeks,
May worsen the skin barrier defect culture for suspected MRS
Inhibit work up
Indirect cost
33 |
33
1110/19/18
Sola
Life with dogs:
The day I thought my dog was dying
If we don’t lead with best medicine, what will be
the next posting on this blog?
34 |
Advantages
ü Rapid response
ü Easy and flexible dosing
ü Short half-life
ü Minimal side effects
ü Approved for all allergic diseases
ü Approved for short and long term use
Important Safety Information
Do not use APOQUEL in dogs less than 12 months of age or those with serious infections. APOQUEL
may increase the chances of developing serious infections, and may cause existing parasitic skin infections or
pre-existing cancers to get worse. APOQUEL has not been tested in dogs receiving some medications including
some commonly used to treat skin conditions such as corticosteroids and cyclosporines. Do not use in breeding,
pregnant, or lactating dogs. Most common side effects are vomiting and diarrhea. APOQUEL has been used
safely with many common medications including parasiticides, antibiotics and vaccines.
See full prescribing information at www.apoquel.com/apoquel_PI
35 |
36
Apoquel® vs Cytopoint®
Short term Long term
Any allergic Atopic dermatitis
Dermatitis
> 1 yr age Dogs < 1 yr
Dogs with serious
infection
Dogs with cancer
36 |
1210/19/18
Fleas and other ectoparasites
More Important Than Ever
All atopic dogs need the best flea control you can provide
Easier to Tx
1 Parasites
Never underestimate the
power of the flea
37 |
The Tampa flea studies support the use of oral
flea control in allergic dogs
Michael W. Dryden 1*, Michael S. Canfield 2, Emily Niedfeldt 1, Amanda Kinnon 1, Kimberly Kalosy 1, Amber Smith 1,
Kaitlin M. Foley 1, Vicki Smith 1, Todd S Bress 2 , Nicole Smith 2, Mike Endrizzi3 , Joyce Login 4 2017. Parasites and
Vectors 10:389.
38 |
39
Reduction in Itch Correlates With Killing of Fleas!
10 Sarolaner n = 29
Sarolaner:: 88.64% improvement by 8 wks 12 0
Spinosad n = 26
9 Spinosad: 85.6% improvement by 8 wks
8 W ITH NO ANTI-ITCH MEDICATIONS 10 0
7
80
6 Close to 100% reduction in fleas
PVAS
5 60
4 40
Medications given by investigators
3 according to label directions
2 20
1
0
0 Da y 0 Da y 7 Da y Da y Da y Da y Da y
Da y 0 Da y 7 Da y 1 4 Da y 2 8 -3 0 Da y 4 0 -4 5 Da y 5 4 -6 0 14 21 28 -3 0 40 -4 5 54 -6 0
Sar ola ne r Spin os ad Sar ola ne r Spin os ad
Dryden, Canfield et al. 2018. Parasites and Vectors 10:389.
39 |
1310/19/18
Even atopic dogs have less inflammation when taking flea
control
80 Sarolaner:: 67.4% improvement by 8 wks
Olivry et al. Vet Dermatology 2014; 25:77 Spinosad: 62.4% improvement by 8 wks
70 W ITH NO ANTI-INFLAMMATORY MEDICATIONS
60
At least a subset of these
CADESI-04 50
dogs are authentically atopic
40
30
20
10
0
Da y 0 Da y 2 8-3 0 Da y 5 4-6 0
Sar ola ne r Spin os ad
40 | Dryden, Canfield et al. 2018. Parasites and Vectors 10:389.
Isoxazolines for broad spectrum ectoparasite control
Ruling out ectoparasites is the Currently available:
first step in our diagnostic – Sarolaner
approach to itch.
– Afoxalaner
What if we don’t suspect – Fluralaner*
scabies and miss it? – Lotilaner*
• *Must be given with food
And what about Cheyletiella
and lice?
TICKS!
41 |
IMPORTANT SAFETY INFORMATION: Simparica is for
Why Simparica®? use only in dogs, 6 months of age and older.
SIMPARICA may cause abnormal neurologic signs such
as tremors, decreased conscious proprioception,
Doesn’t have to be given with ataxia, decreased or absent menace, and/or
seizures. Simparica has not been evaluated in dogs
food that are pregnant, breeding or lactating. Simparica
has been safely used in dogs treated
Kills fleas, ticks and mites! with commonly prescribed vaccines, parasiticides
and other medications. The most frequently reported
adverse reactions were vomiting and diarrhea.
Priced right! www.zoetisUS.com/SimparicaPI
Safe
42 |
1410/19/18
“Apoquel isn’t
working anymore”
• No flea control
• Suboptimal flea control
43
43 |
• Topical flea control – pyoderma
every fall
Dobby: my why
• Oral flea control –Simparica®-
no more pyoderma in the fall
44 |
Infection Control Essential
Targeted therapeutics won’t control this itch well
Easier to Tx
2 Pyoderma, yeast infection
• Antibiotics and/or antifungals
• Topical therapy (chlorhexidine)
Harder to Tx
Michele Rosenbaum
45 |
1510/19/18
Major cause of perceived Apoquel® or
Cytopoint® failure for me
46 |
Malassezia dermatitis
Azoles 5 mg/kg/day OR terbinafine 30-40 mg/kg/day
Bathing with 3% chlorhexidine or chlorhexidine/azole
shampoo
Pulse antifungal therapy and/or Malassezia
immunotherapy
47 |
48
Cytopoint Effective Every Month for 10
months then stopped working. Why?
48 |
1610/19/18
A role for food allergy in atopic dermatitis
A subset of atopic dogs will have food triggers: find and avoid
Easier to Tx
Nonseasonal itcher
+/- GI signs
3 Food allergy
Harder to Tx
Michele Rosenbaum
49 |
50
You want
these papers!
50 |
Apoquel® For Food Trials
During the first 6-8 weeks of a food trial
Itch comes back quickly
Not food allergy, move on
Start diet
Itch does not come back
Probable food allergy, challenge
Start Apoquel® Stop Apoquel®, continue diet
51 |
1710/19/18
Is there still a role for allergy immunotherapy?
Absolutely! The ideal candidate
Atopic dermatitis is a life long A young dog with moderate to
disease severe disease
Immunotherapy may help stop the Non-seasonal/long season
progression of the disease
Difficult to control with medications
The goal is medication reduction
A motivated owner
“Immunotherapy is an investment in
your pet’s future”
52 |
Changing the Immune System:
Allergen Specific Immunotherapy
SCIT SLIT
Sasha Before and 6 months into SLIT
1810/19/18
Living Life Large!
55
55 |
What can topical barrier repair add to the
comfort of our itchy dogs?
Additive itch and
inflammation
control Allergic dermatitis
Superficial pyodermas
Keratinization disorders
Dry skin
Better pyoderma
control
56 |
57
Skin Barrier Defect: Repair with
nutrition and topical lipids
Healthy Barrier Disrupted Barrier
57 |
1910/19/18
Available Products
DOUXO® line of shampoos, sprays, mousses, gels, wipes, spot-on
contain phytosphingosine (CEVA)
Ceramide complex in shampoos, spray, wipes in several of the
Dechra line of topical products
Ceramides in VetBiotek products
Dermoscent® Essential 6 and other products from LDCA containing
a mix of essential oils from herbs and grains
58 |
Dermoscent® Laboratory
Combines essential oils of herbs and grains to take advantage of
natural anti-inflammatory, antimicrobial capabilities
Supplies essential fatty acids directly to the skin
Pleasant herbal aroma is deodorizing
59 |
• 23 atopic dogs treated with 8 weekly applications of Dermoscent® Essential 6
• 12 dogs with moderate to severe atopic dermatitis; 11 with mild disease
• 25 atopic dogs treated with 8 weekly applications of placebo
• 16 dogs with moderate to severe atopic dermatitis; 9 with mild disease
60 |
2010/19/18
Weekly treatment with Dermoscent® Essential 6 reduces itch
and inflammation in atopic dogs
Imagine the effects when we combine Apoquel® or Cytopoint® with topical barrier repair
61 |
Cytopoint® now approved
HOT OFF THE PRESS!
for the treatment of all
allergic dermatitis
62 |
Cytopoint® now approved
HOT OFF THE PRESS!
for the treatment of all
allergic dermatitis
63 |
2110/19/18
Precision Sustained
64 |
65
If Apoquel® or Cytopoint® stop working
Always check the ectoparasite control
– Isoxazolines for their broad spectrum
Look for the infection
– For dogs with recurrent yeast, think yeast hypersensitivity,
consider immunotherapy and/or pulse antifungal therapy
– For dogs with recurrent pyoderma, increase bathing, use
barrier repair, and consider SPL
Think about barrier repair - it can really help
Seasonal flares can occur
65 |
Referral always an option J
A Partnership For the Allergic Pet:
When to Refer
Caregiver Non-seasonal itch, skin/ ear inflammation
– Benefit from immunotherapy,
especially when young
Refractory pruritus cases
Unusual skin lesions
Recurrent or non-responsive skin or ear
infections
Help create/ reinforce long-term
preventative maintenance plan
Refer early for best results
Dermatologist Family
Veterinarian
66 |
2210/19/18
67
The Fadok Caveat:
If it is weird, biopsy it!
Cutaneous T cell lymphoma Pemphigus foliaceus
67 |
23Practical Dermatology Updates: Overview
Fighting the Fungal and
Ø Dermatophytosis review and
Demodex Funk diagnostic/treatment updates
Ø Malassezia dermatitis review and
Brian S. Palmeiro, VMD, DACVD
updates
Ø Demodicosis review and treatment
updates
skin@lehighvetderm.com
DERMATOPHYTOSIS
DERMATOPHYTOSIS Dog
Ø Dog
Ø Generalized
Ø Localized is most common
Ø Breed
Ø Circular alopecia
predisposition
Ø Kerion
Ø Yorkie is like a cat
Ø Form of localized
dermatophytosis in dogs when it
that is nodular due to rupture comes to
of hair shafts (furunculosis) ringworm
Ø Generalized less common Ø Jack Russell
Ø Occurs in certain breeds Ø Underlying
Ø Yorkies, Jack Russell immunosuppression
Ø Rarely
in immunosuppressed in some cases
animals
DERMATOPHYTOSIS
Cats
Ø More common in cats
than dogs
Ø Many different clinical
appearances
Ø Alopecia, crusting, scaling = most
common
Ø Should be a differential for any skin
disease in the cat
Ø Long-haired cat breeds such as
Persians and Himalayans
predisposed
Ø Very common in young cats
Ø +/- Pruritus
1Dermatophytosis
Diagnosis Woods Lamp
Ø Screening Tests
Look for apple
Ø Direct microscopy Examine hair coat
green fluorescence in hairs
Ø Trichogram in dark room with Wood’s Lamp
Ø Wood’s lamp
Ø Apple-green
Principle
fluorescence
Tryptophan metabolite of
Ø Culture dermatophyte fluoresces under
Ø ID of the fungus UV light (253.7 nm)
Ø GOLD Wavelength is temperature
dependent, so allow lamp to
STANDARD
heat up for 5-10 minutes
Ø Skin biopsy
Ø PCR
Wood’s lamp pros vs. cons Fungal Culture
Ø Pros Ø Gold standard for diagnosis of
Ø Fast dermatophytosis
Ø Inexpensive Ø Techniques
Ø Screening Ø Active lesions - Use hemostats to
Ø Selection of infected hair collect hair and scale from periphery
for culture/trichogram of lesion
Ø Inoculate hair onto media or send hairs in
Ø Cons sterile red top tube to lab
Ø Less than 50% Microsporum canis strains Ø Hemostats - Wrap individually and
fluoresce autoclave
Ø False positives: scales, crusts, topical Ø No active lesions or asymptomatic
medications carriers
Ø Sterile tooth brush culture
2Dermatophyte Test Media Fungal Culture
Fungal culture Pitfalls
Ø Must be evaluated DAILY for growth and
Ø DTM has proteins/carbs
Ø Dermatophytes use color change
protein first producing Ø Labor intensive
alkaline byproducts Ø Failure to check results in contaminant
which turns the phenol overgrowth
red in the media red
Ø False negatives
Ø Saprophytes use up
Ø False positives – mistaking contaminant color change
carbohydrates first (no
for dphyte associated color change
color change) and
consume protein later Ø Color change only useful for 10-14 days
Ø 10 to 14 days prior to Ø MUST be taped out/identified
color change
Ø Color change is NOT sufficient for diagnosis
Fungal Culture
Dermatophyte PCR
Ø Commercial laboratories have recently
Ø Avoid small slant jars or started to offer PCR assays for
small DTM discs dermatophytosis
Ø Insufficient media
Ø Overgrown by contaminants rapidly Ø PCR test for dermatophytosis (IDEXX
Ø Difficult to tape-out small colonies Laboratories RealPCR™, a real-time PCR)
Ø If doing in house has been evaluated in two recent studies
Ø Must check DAILY Ø Screens for infection with Microsporum spp., Microsporum
canis and Trichophyton spp
Ø Use larger media plates with half
Sab/dex agar and half DTM Ø 1-3 working days for results
media Ø Soft bristle toothbrush to comb the suspect lesion. Plucked
hairs and/or crusts can be submitted in a red-top tube
Ø Must ID macroconidia!!
Dermatophyte PCR
Dermatophyte PCR
Ø Cross-sectional
study of 132 shelter cats
Ø 52 cats with clinical lesions (Jacobson 2018 J Feline Med Surg. February 2018;20(2):103-107)
Ø Hair samples were collected for fungal culture and PCR prior
Ø PCR and DTM culture results matched in 49
to treatment and at weekly intervals until two neg cultures
cats (94.2%) (Moriello & Leutenegger 2017)
Ø PCR correctly identified ALL culture-positive
Ø Of post treatment cured cats (2 neg cultures) cats and 92/104 culture negative cats; there
some had false positive PCRs were 12 false-positive PCR results
Ø Microsporum spp. PCR assay 16/46 (35%) Ø Sensitivity 100%; Specificity 88.5% for diagnosis
Ø M. canis PCR assay 7/46 (15%)
Ø Unreliable for identifying mycological cure
Ø False positives: 64.7% (11/17) of first and second negative
DTM cultures
3Practical Use of
PCR
Dermatophyte PCR
Pros Cons
Ø Fast Ø False positive results Ø Better as a diagnostic test for active
Ø Results in 1-3d Ø Non-viable
infection/initial diagnosis and not as a
compared to 21d for dermatophytes
culture Ø Environmental
guide for when to stop treatment
Ø Less room for user error contaminants (mycological cure) due to false positives
Ø Less time consuming Ø False negatives Ø Ideally combined with fungal culture
Ø Fungal cultures need Ø Sample quality
Ø Can be used to get an early start on tx if
to be checked daily Ø Not as useful for positive
monitoring response to
treatment/mycological Ø IDEXX lab because clinically studied
cure
Dermatophytosis Treatment Dermatophytosis Treatment
Dog Cat
Ø **Systemic
therapy
Ø Localized (excluding kerions)
REQUIRED
Ø 1 lesion: topical therapy alone often effective
Ø Itraconazole - approved
Ø Topical – miconazole, clotrimazole,
Ø Fluconazole
terbinafine
Ø Terbinafine
Ø Generalized, kerions or numerous lesions:
Ø Topical therapy
Ø Systemic treatment mandatory
Ø Lime–sulfur dips = topical of
Ø Azoles (fluconazole, itraconazole) choice
Ø Terbinafine
Ø Decreases environmental
Ø Topical therapy contamination
**WHEN IS IT SAFE TO DERMATOPHYTOSIS
Treatment
STOP TREATMENT** Ø If possible, infected animals should
Ø Treat until at least 2 be kept in an area of the house that
can be safely/easily cleaned and
consecutive negative
disinfected
fungal cultures are Ø Infected animals should be
obtained!!! isolated from negative animals
Ø If no lesions, use sterile Ø Culture of all in-contact animals
toothbrush to brush cats Ø Asymptomatic carriers common
coat Ø Tooth brush culture
Ø Inoculate bristles into fungal Ø Zoonotic risk!!!
media Ø Up to 60% of humans in household will
develop lesions
4USCAFITR00020
Itraconazole Itraconazole – Side Effects
Ø GI upset (vomiting, diarrhea, anorexia)
Ø One of most commonly used azole
antifungals for dermatophytosis in cats Ø Elevated liver enzymes
Ø Itrafungol™, liquid 10 mg/ml Ø Cutaneous vasculitis in dogs at 10 mg/kg dosing
Ø Only APPROVED treatment for Ø Itrafungol™ has been assoc with renal changes found on histopath
dermatophytosis in cats that were not noted after an eight week recovery period
Ø Highly keratinophilic Ø Use with caution in cats with renal dysfunction
Ø DO NOT COMPOUND: Pharmacokinetic studies relative Ø Negative inotropic effects reported in dogs humans volunteers (IV)
absorption - 2% to 8% of reference formulation values Ø Cats w/heart disease should monitored during treatment
Ø PUSLE DOSING
Ø Cytochrome P450 inhibitor
Ø Dose = 5 mg/kg SID on alternating weeks for 3 treatment cycles
Ø May increase plasma concentrations of other drugs metabolized
by this pathway, such as amitriptyline, amlodipine,
benzodiazepines, buspirone, cisapride, corticosteroids, 4
Elanco Animal Health. Data on File.
cyclosporine, ivermectin, and macrolide antibiotics
Terbinafine
Fluconazole Ø Belongs to the newest class of antifungals: Allylamines
Ø Increased use for dermatophytosis with availability of Ø reversibly inhibits squalene epoxidase, decreasing sterol (mainly ergosterol) synthesis and
results in an accumulation of squalene in the fungal cell membrane
affordable generic product
Ø No prospective studies to date but commonly used to treat Ø Now generic and affordable
dermatophytosis Ø Dosing for dermatophytosis in cats
Ø 5-10 mg/kg once daily Ø 30-40 mg/kg SID (Lower doses don’t work)
Ø Water soluble Ø Concentrates in the hair (Vet Derm 07)
Ø Gastric pH or the presence of food, do not appreciably alter Ø After 14 days of oral tx, half life in hair 1.8 wks
fluconazole’s oral bioavailability Ø Above MIC90 for 5 weeks!! Pulse Dosing likely possible but not fully
Ø Excreted via kidneys in its active form; drug is evaluated
concentrated in urine Ø Does not affect P450 enzyme system like azoles
Ø Dose reduction with renal disease Ø Side effects
Ø Very, very low affinity for mammalian P-450 enzymes Ø GI (4/14 in recent study)
Ø Excellent safety profile Ø Increased liver enzymes – rare
Ø Facial pruritus/cutaneous drug eruption (2/14)
Topical Antifungals
Ketoconazole
Ø Adjunct to systemic treatment to
Ø In-vitroactivity against M.canis hasten resolution and to decrease
decreased compared to other azoles environmental contamination
Ø Side effects and monitoring: Ø Whole body topical treatment is
Ø Nausea and vomiting most common preferred over spot treating visible
Ø DON’T USE IN CATS lesions
Ø GI, Hepatoxicity/YELLOW
Ø Liver toxicity is uncommon, but possible in dogs Ø Lime-sulfur dips or sprays
Ø Beware of drug interactions: Ø Topical treatment of choice
Ø Suppression of drug metabolism via down- Ø Douxo chlorhex/climbazole shampoo
regulation of P450 microsomal enzymes Ø In vitro study w/T.verrucosum from bovine hairs
Ø Higher cost since FDA required label change to limit
use Ø Enilconazole
Ø Not available in US, but very effective topical
5Lime Sulfur Environmental Decontamination
Ø Most effective topical antifungal tx available Ø Can be a difficult aspect of treatment due to resistant spores
Ø Topical therapy of choice for dermatophytosis Ø Infective spores are contained within shed hairs
Ø Safe for puppies and kittens Ø Infective spores can remain viable in the environment for up to
18 months, most live 3-6 months, shorter w/higher humidity
Ø Typicallyused as dip Ø SOURCE OF REINFECTION!!
Ø Applied once weekly Ø Bigger issue in multi-cat households, catteries, shelters
Ø Most important part of decontamination is the hard clean
Ø Side effects Ø Mechanical removal of organic debris/hairs followed by washing of the
Ø Very strong odor surface with a detergent
Ø Stains multiple surfaces (fabrics, jewelry etc.) Ø Often includes sweeping or vacuuming followed by washing
Ø Mucous membrane irritation (wear E-collar while dries) Ø Allows for mechanical removal of spores
Ø Making the lime sulfur into a spray and spraying the Ø Electrostatic cleaners such as Swiffers™ or damp mopping in
preference over sweeping where possible
entire coat can improve compliance Ø Follow with disinfectant
Ø Dilute 1:32 in spray bottle
Environmental Decontamination
Disinfecting Environmental Decontamination
Ø Discard fomites that can’t be thoroughly treated
Ø Disinfectant is typically used after the hard clean; 10 Ø cat towers, collars, clothes
minute contact time Ø Cleaning clothes:
Ø Effective disinfectants Ø Dry cleaning is effective at killing spores.
Ø Sodium hypochlorite: 1:10 and 1:32 dilution of household Ø Washing machine - use the longest cycle highest water level
and wash clothing twice. If possible, bleach should be used
bleach are typically effective, but not safe on all surfaces
Ø Enilconazole but not approved for household use in US Ø Carpets
Ø One of the most difficult surfaces to disinfect
Ø Accelerated hydrogen peroxide
Ø Frequent vacuuming!!!
Ø OTC products with a label claim against
Ø Steam cleaning does not kill all infective spores
T.mentagrophytes (including active ingredients such as
Ø Steam cleaning of intentionally contaminated carpets removed >95% of
sodium hypochlorite, quaternary ammonium, lactic acid, spores 48 hours post cleaning (Moriello 2014)
accelerated hydrogen peroxide and ethoxylated alcohol Ø Carpet shampooing - carpets were negative 7-10 days after
mixture) shampooing (Moriello 2014)
Malassezia Dermatitis
Ø Erythema, lichenification, hyperpigmentation,
adherent waxy scale,
crusting,
bronzing/brown
discoloration,
greasiness
Ø M.pachydermatis
Ø Most commonly
assoc with underlying
hypersensitivity
6Malassezia Dermatitis - Malassezia Paronychia
Diagnosis
Ø Very common
Ø Cytology in atopic dogs
>1 yeast per oil field
Ø
Ø Cause
Is significant, for pedal
especially in patients
pruritus
with compatible
clinical signs Ø Use non-pointed
Ø Techniques
toothpick or
broken cotton tip
Ø Tape impression
applicator to
Ø Direct impression
sample claw fold
Ø Swabs
Ø Systemic therapy best to resolve
Malassezia Hypersensitivity Treatment of Malassezia Dermatitis
Ø Common in atopic patients with recurrent yeast dermatitis/otitis Ø In vitro studies have shown better susceptibility to
Ø Diagnosis – Intradermal testing or serum IgE ketoconazole and itraconazole compared to terbinafine,
Ø Substantial agreement was demonstrated between IDT reactivity and fluconazole and miconazole
HESKA Malassezia IgE (77% sensitivity, 89% spec; Oldenhoff 2014)
Ø Ketoconazole 5-10 mg/kg once daily
Ø Breed predispositions
Ø Hounds, Labradors, Westies/terriers Ø Fluconazole 5-10 mg/kg once daily
Ø Treatment options Ø Itraconazole 5 mg/kg once daily
Ø Allergy management Ø Pulse therapy also effective
Ø Topical therapy
Ø Pulse dosing antifungals
Ø Terbinafine 30 mg/kg once daily
Ø Targeted specific immunotherapy with Malassezia Ø Pulse therapy also effective
Good response to SCIT in 9/16 cases (56%) with both a reduction in use of
Ø
Ø Resistance is rare but reported
anti-inflam, antifungals and >50% reduction in pruritus scores (Aberg 2017)
Malassezia Dermatitis
Terbinafine for Malassezia
Topical Therapy
Ø Generally considered to be less effective than azoles with
Ø Higher MICs Ø DBPC study showed best efficacy with
Ø Efficacy of ketoconazole (10 mg/kg SID) and terbinafine (30 miconazole/chlorhex shampoo for MD in
mg/kg once daily) for 21 days found no significant difference
in outcome
basset hounds when compared to
Ø Pilot study comparing the efficacy of terbinafine given at 30 selenium sulfide
mg/kg once daily for 21 days vs. pulse dosing (30 mg/kg
given once daily for 2 consecutive days per week) found no
Ø Based on in vitro studies, chlorhexidine
difference in outcome of at least 3% when used alone
Ø Pharmacokinetic study of terbinafine in dogs 30 mg/kg SID x performs better for Malassezia than
21 days
Ø Concentrations of terbinafine did not achieve high levels in the stratum lower percentages
corneum and sebum compared to the serum
Ø Levels barely exceeded MIC90 for Malassezia (Gimmler et al 2015)
Ø Best to use a shampoo w/comb of
Ø Higher doses may be needed chlorhex and azole antifungal
7Malassezia Biofilm Pulse Dosing Antifungals to
Ø Malassezia are strong producers of biofilms
Control Recurrent MD and MH
Ø Itraconazole 5 mg/kg PO q 24 hrs for 2
Ø Improve microbial attachment; facilitate evasion
from the host’s immune system; act as a barrier consecutive days per week.
against antimicrobials Ø Persistence in stratum corneum
Ø In a recent study, ketoconazole and Ø As effective as daily ketoconazole or
fluconazole produced the best inhibition of itraconazole
mature Malassezia biofilm compared to Ø Terbinafine 30 mg/kg PO q 24 hrs for 2
other azoles (voriconazole, itraconazole), consecutive days per week.
terbinafine and amphotericin B (Samia et al Ø No significant clinical and cytological
2018) difference was seen between once daily
and twice weekly oral administration
Pulse Dosing Antifungals to Take Home Messages for
Control Recurrent MD and MH Malassezia Dermatitis in Dogs
Ø My pulse dosing schedule Ø Don’t be afrraid of systemic antifungals to manage
Ø Utilize fluconazole most commonly Malassezia dermatitis
Ø Treat once daily for 3-4 weeks Ø Common allergen in atopic dermatitis
Ø Then try alternate week dosing (7 days on, Ø Consider pulse dosing to prevent recurrent
7 days off) Malassezia dermatitis and control Malassezia
hypersensitivity
Ø If more itchy on off weeks, try 2-4 days per
week dosing Ø Work up and manage underlying allergy
Ø Efficacy of immunotherapy with Malassezia allergen
Ø Maintenance antifungals for MH in ears
extract to control Malassezia hypersensitivity
Ø Ketoconazole 1% in ear cleaner base and
topical steroid (dexamethasone)
Malassezia in Cats Canine Demodicosis
Ø Can be seen secondary to allergic skin
disease Ø3 Species
Ø Malassezia otitis or dermatitis
Ø Demodex canis*****
Ø Can affect the feet and claw beds,
Ø Demodex injai
Ø Cornish Rex, Devon Rex and bald cats
Ø long bodied
Ø Canbe seen secondary to
Ø Demodex cornei
severe/internal disease
Ø short bodied
Ø Paraneoplastic alopecia, erythema
multiforme, thymoma assoc dermatosis
8Diagnosis of Demodicosis
Localized Demodicosis
Ø DEEP skin scraping is Ø Young dogs 90% will resolve on own in 4-8
Ø Hair plucking weeks
Ø Useful in difficult to scrape places Ø Miticidal therapy not recommended
Ø Interdigital, face Ø Need to determine which cases will
Ø Screening tool progress to generalized disease
Ø 85% positive compared to skin Ø Topical antimicrobials (benzoyl
scrapings peroxide, bathing etc.)
Ø If negative but suspected, skin
scraping should still be Ø Evaluate for other stressors
performed including internal parasites
Ø Cytology Ø Recheck exam/scrapings 3-4
weeks
Ø Biopsy
When Is Demodex Considered Generalized Demodicosis
Generalized? Juvenile Onset
Ø >4 lesions
Ø Especially if numerous life Ø Pathogenesis
stages on scrapings unclear but likely
Ø 1 entire body region involves mite specific
immunodeficiency
Ø Lesions involving feet
Ø HERITABLE:
(pododemodicosis)
affected animals
Ø Spreading or persisting for should not be used
greater than 6 months for breeding
Ø ANY adult onset case
Generalized Demodicosis What's New in the treatment of
Adult Onset Demodicosis? Isoxazoline Parasiticides
Ø Can be secondary to
immunosuppression Ø Four recent studies have shown efficacy of
Ø Hypothyroidism, Cushing’s, DM, Neoplasia Bravecto™, NexGard™, Simparica™ and
Ø Immunosuppressive therapy: Pred, Credelio™(all labeled for the control of fleas
Azathioprine, chemo drugs
Ø Allergy drugs – Apoquel™ Atopica™
and ticks in dogs) for canine demodicosis
Ø MUST SEARCH FOR UNDERLYING CAUSE Ø Mounting anecdotal evidence of success
Ø CBC, chem, u/a, T4/fT4/TSH
with these products
Ø Imaging to rule out neoplasia
Ø May not find underlying trigger Ø Many veterinarians and vet dermatologists
in some cases (>50%) now using these products as treatment of
Ø Shih Tzu choice for generalized demodicosis in dogs
prior to reaching for ivermectin
9Fluralaner (Bravecto™) and
Demodicosis Alfoxolaner (NexGard™)
Ø A recent study (Foire 2015) in 16 dogs Ø Recent study in 8 dogs (Beugnet et
compared the efficacy of Bravecto™ with al 2016) with generalized
the Advocate® (imidacloprid/moxidectin), demodicosis were treated with the
for generalized demodicosis in dogs. recommended dose on days 0, 14,
Ø After single oral administration of 28 and 56. Efficacy was compared
Bravecto™, mite numbers in skin with 8 dogs on Advocate®
scrapings were reduced by 99.8% on Ø The percentage reductions of mite
Day 28 and by 100% on Days 56 and counts were 99.2%, 99.9% and
84.
100% on Days 28, 56 and 84,
Ø Extralabel use for demodicosis at label respectively all significantly higher
dosing than Advocate group
Sarolaner (Simparica™) Lotilaner (Credelio™)
Ø 16 dogs with generalized Ø 10 dogs with generalized
demodicosis demodicosis were assigned
Ø Group 1: sarolaner (2 mg/kg) orally to a single group orally
on days 0, 30, and 60.
treated with lotilaner
Ø Group 2: imidacloprid/moxidectin q
7d from day 0 to day 81 (min 20 mg/kg) on Days 0, 28 and 56
Ø Sarolaner tx group, Ø 9/10 dogs were negative by day 28
pretreatment mite counts were Ø No live mites were detected after Day 56
reduced by 97.1% at 14 days out to and including Day 84 post-treatment
and 99.8% by 29 days after the for 100% efficacy of each dog's Demodex
first dose. No live mites were mite infestation
detected after day 29
Young Dogs with Demodex What About Dogs with
Ø Credelio™ MDR1/ABCB1 mutation
Ø 8 weeks of age and weighing at least 4.4lbs Ø Bravecto™ (Walther 2014)
Ø NexGard™ Ø Well tolerated in MDR1-/- Collies at 3x
Ø 8 wk of age and older and weighing 4 lb and dosing
greater Ø NexGard™ (EMA 2013)
Ø Simparica™ Ø Well tolerated in MDR1-/- collies following
Ø >6 mo of age and >1.3 kg (2.8 lb) single oral administration at 10x dosing
Ø 8 weeks in Europe Ø Simparica™
Ø Bravecto™ Ø Well tolerated in MDR1-/- following single
Ø 6 mo of age and older and weighing 4.4 lb and oral administration at 5x dosing
greater
10Flavoring in Isoxazolines
Ø Credelio™
Treatment
Ø Stilltreat until at least 2 negative scrapings
Ø Pork liver and soy
are obtained at monthly intervals
Ø NexGard™
Ø Antibiotics may not be as important for
Ø Beef flavoring (synthetic),
maize/cornstarch, soy protein fines outcome as initially thought, but are always
indicated with deep pyoderma (Kuznetsolva
Ø Simparica™
et al. 2012)
Ø Pork liver and hydrolyzed soy
Ø Treatment failures to Isoxazolines are
Ø Bravecto™
definitely possible in which case daily
Ø Pork liver flavor, maize/cornstarch
ivermectin protocol is typically utilized
What about Scabies?
Demodex injai
Ø There are publications Ø Long bodied follicular demodex
illustrating efficacy of Ø Livesin seb gland and hair follicle
Bravecto (single dose)
Ø Dorsal greasy skin and coat in terriers
and Simparica (2 doses
Ø Wire haired fox terriers
one month apart) for the
Ø Westies
treatment of sarcoptic
mange in dogs when Ø Typicallyhave
used at label dosing concurrent
Ø Extra-label allergic skin disease
Short Bodied Demodex Mite in
Dogs Feline Demodicosis
Ø Suggested name Demodex
cornei
Ø3 species
Ø Morphological variant of
D.canis Ø Demodex gatoi
Ø ½ length of D.canis Ø Pruritic, superficial
Ø Inhabits the stratum corneum
Ø Demodex cati
Ø Similar to the short bodied
mites in hamsters, cats Ø Third unnamed species recently identified
Ø Seen on scrapings of dogs
with high levels of D.canis
mites
Ø Clinical presentation and
treated as for D. canis
11Demodex gatoi
Ø Inhabits the stratum corneum
Ø FOUND ON SUPERFICIAL SKIN SCRAPINGS
Ø Short and stubby
Ø Can be difficult to find
Ø Occasionally found on fecal exam
Ø Pruritus – head, neck, ventrum
Ø Symmetrical alopecia common
presentation
Ø More common in southern US
and Gulf Coast
Ø Contagious
Ø Treat all in contact cats!
Ø Asymptomatic carriers reported
Ø May be more likely to find mite
Ø Treatment
Ø Lime sulfur dips weekly x 6 weeks – most effective tx
Ø Anecdotal reports of Advantage Multi (q 2 wks) and Bravecto™
Demodex cati
Ø Uncommon
Ø Follicular, long bodied Mite
Ø Alopecia, crusting, ceruminous otitis
Ø Underlying immunosuppression
Ø Corticosteroid administration
Ø FeLV/FIV, diabetes
Ø Neoplasia
Ø Locally at site of SCC
Ø Lymphoma
Ø Treatment
Ø Weekly lime sulfur dips
most effective
Ø Anecdotal reports of
Advantage Multi™
1210/19/18
*
Valerie A. Fadok, DVM, PhD
Diplomate, ACVD
Zoetis, valerie.fadok@zoetis.com
*Cephalexin became generic; we used it!
*Courses ran from 14-42 days.
*We combined cephalexin with steroids because we knew the
cephalexin would work
*We got lazy about bathing.
*Repeated courses of cephalexin throughout year
*We used pulse antibiotics.
*7-10 days per month.
*2-4 days per week.
*
*Emergence of MRS in veterinary
medicine
*Increased focus on underlying
cause
*More reliance on topical therapy
*Choosing and using antibiotics
wisely Moziru.com
*Efficacy and safety
*Compliance and value
*No more pulse antibiotics
*
110/19/18
*Verify that infection is present
(cytology)
*Determine the underlying cause
and use topical therapy
*Know your pathogen
*Do rechecks to assess response
*Educate staff and clients about
pyoderma
*
*Saijonmaa-Koulumies LE, Lloyd
DH. 2002. Vet Dermatol 13:123
*Saijonmaa-Koulumies LE et al.
2003. Epidemiol Infect 131:931
*
Perineum 66%
Nose 27% Groin 23%
Mouth 65%
Paul NC et al. 2012. Vet Microbiol 160:420
210/19/18
*
*
S. pseudintermedius is an opportunist
Secondary infections
Underlying causes can include:
Parasites (demodicosis, scabies)
Allergies (flea, food, atopy)
Keratinization/follicular keratinization disorders (seborrhea,
color dilution alopecia)
Endocrinopathies (hypothyroidism, hyperadrenocorticism,
diabetes mellitus)
Poorly characterized immunologic/barrier defect
Staph hypersensitivity?
*
*S.aureus
*S. schleiferi
*P.aeruginosa
Leonard FC, Markey BK. Vet J. 2008 Jan;175:27-36
Weese JS. ILAR J 2010;51:233-44.
Rich M. Br J Biomed Sci 2005; 62:98-105
May ER et al. Vet Microbiol 2012; 160:443-8
Kunder DA et al. Vet Dermatol 2015; 26:406-410
Hillier A et al. Vet Dermatol 2006; 17:432-9.
Arais LR et al. Vet Dermatol 2016; 27:113-7.
310/19/18
*Clinical exam
*Cytologies
*Impression smear
*Clear tape
*Crust macerated in saline
*Culture and sensitivity
* Pictures courtesy
Tiffany Tapp
*
11
*Postgrooming furunculosis
410/19/18
*
*
Mixed Staph + yeast
Courtesy, Carol Foil 14
*
*2 week recheck on all dogs taking antibiotics for pyoderma
* If you do not see at least 50% improvement, culture
* Do not have to stop antibiotics to culture the skin
*Development of new lesions while taking antibiotics
*Failure to completely resolve after 6 weeks
*Mixed infections with cocci and rods
Hillier A et al. Vet Dermatol 2006; 17:432-9.
510/19/18
*
• Rupture intact pustule,
papule w/ 25 g needle
• Lift edge of crust, rub
culturette underneath
• Moisten swab, rub across
surface of collarette
• For deep pyoderma- needle
aspirate, macerated tissue
culture
*
• Topical therapy is ALWAYS important
• The power of the bath
• Pick correct antibiotic at the correct
dose for the correct duration!
*
*Is an antibiotic necessary?
*What is the most
appropriate antibiotic?
*What dose, frequency,
duration?
*What do we do to improve
the chances of success?
*Modern microbiology
*Efficacy for your organism
*Best in class
*Consider compliance
610/19/18
*Do you need a systemic antibiotic?
*Surface pyodermas are best treated with topical
therapy
*Fold pyodermas
*Bacterial overgrowth
*Impetigo
*
*
Bacterial
Overgrowth (BOG)
710/19/18
*
*What topical therapy?
*Evidence for chlorhexidine is best
*In vitro
*In vivo
*The more the client will bathe, the faster the dog will
improve
*Shortens course of antibiotic therapy
*
* Response to 2 weeks of daily chlorhexidine baths
NO ANTIBIOTIC USED
Murayama et al. VETERINARY
24 DERMATOLOGY
Volume 21, Issue 6, December 2010, Pages: 586–592,
810/19/18
*
Total Lesion score Percentage of cure at D49
14 Rela pse Clini cal cure
12
10
8
6 76
100
4
2 24
0
0
D0 D7 D14 D22 Cepha lexin+Douxo Cepha lexin al one
Chlor Protocol
Cepha lexin+Douxo Chlor Protocol
Cepha lexin al one
Data courtesy Sogeval
S = systemic (amoxicillin clavulanate)
T = topical
910/19/18
Sodium hypochlorite, salicylic acid
*
Start
2 weeks
Dexter
4 weeks
*
MIC’s 1000x lower than concentrations
used in clinical practice
Valentine BK et al. Vet Dermatol 2012; 23:493
1010/19/18
12 dogs with superficial pyoderma treated with cephalexin and either
PyoClean® spray on one side of the body or placebo spray on other side
Dermoscent® Laboratory
*
Folliculitis
Superficial spreading pyoderma (Staph HS)
Short haired dog pyoderma
Epidermal collarettes
www.soc.ucsb.edu
1110/19/18
*
*
*
1210/19/18
*
Furunculosis
Cellulitis
*
Golden Retriever Hot Spots
1310/19/18
*When topical therapy alone is not effective
*When owners are unable to bathe frequently enough
*When the infection is generalized/itchy
*Deep/mixed infections
*
*What antibiotic to choose?
*Has the animal been treated before?
*What was the response?
*Know the pathogen
*Your average S. pseudintermedius not sensitive to penicillins and
tetracyclines
* > 50% resistance
* Some geographic variation
*Many veterinarians choose a beta-lactam drug for empiric treatment of
S. pseudintermedius
* Greater than 95% isolates reported as sensitive to beta lactams if not MRS
Ravens PA et al. Aust Vet J 2014; 92:149
*
Priyantha R et al. Can Vet J 2016; 57:65
Hillier A et al. Vet Dermatol 2014; 25:163
Antibiotics
Time-Dependent Vs.Concentration-Dependent
Roberts JA et al. Critical Care Medicine 2008; 36:2433-2440.
1410/19/18
*Amoxicillin clavulanate
*Cephalosporins
*Clindamycin
*Macrolides (erythromycin, clarithromycin,
azithromycin)
*
Hillier A et al. Vet Dermatol 2014; 25:163
*
*Clindamycin or lincomycin *Potentiated sulfas
*Amoxicillin-clavulanate *Cefpodoxime
*Cephalexin *Cefovecin
*Cefadroxil IM PO RTAN T SAFETY IN FO RM ATIO N : People w ith know n hypersensitivity to
penicillin or cephalosporins should avoid exposure to CONVENIA. Do not use
in dogs or cats w ith a history of allergic reactions to penicillins or cephalosporins.
Side effects for both dogs and cats include vom iting, diarrhea, decreased
appetite/anorexia and lethargy. See full Prescribing Inform ation
Hillier A et al. Vet Dermatol 2014; 25:163 IM PO RTAN T SAFETY IN FO RM ATIO N : People w ith know n hypersensitivity to penicillin
or cephalosporins should avoid exposure to SIMPLICEF. Do not use in dogs w ith
know n allergy to penicillins or cephalosporins. See full Prescribing Inform ation.
*
*Doxycycline or minocycline *Vancomycin
*Chloramphenicol *Linezolid
*Fluoroquinolones *Teicoplanin
*Rifampin
*Aminoglycosides
Hillier A et al. Vet Dermatol 2014; 25:163
1510/19/18
*
* Designation as 3rd generation cephalosporin
* Recommendations for use vary by country
* What is a 3 rd generation cephalosporin?
* Time of development
* Spectrum of activity
* General rule: 3 rd generation tend to have more Gram - activity,
less Gram + activity
* Concern that their effects on resistance in Enterobacteriaceae may be
more severe than other antibiotics. True or False?
*FALSE
* Studies performed to determine resistance profile of fecal E. coli in
131 dogs receiving antibiotics.
* Antibiotics used included: amoxicillin clavulanate, cephalexin,
cefovecin, clindamycin, enrofloxacin
* All dogs taking antibiotics had increased antimicrobial resistance in E.
coli BUT reverted to baseline by 1-3 months. No one antibiotic worse
*
Schm idt V, Snoop S, Daw son S, et al. Abstract, BSAVA Congress 2014; April 3-6, 2014; Birm ingham , United Kingdom .
Belas A, Salazar AS, Gam a LT, Couto N , Pom ba C. Vet Rec. 2014;175(8):202.
Schm idt V, W illiam s NJ, Daw son S, M cEw an N, Pinchbeck G, Nuttall TJ. Poster, 3rd ASM -ESCMID Conference on Methicillin-resistant Staphylococci
in Anim als: Veterinary and Public Health Im plications; Novem ber 4-7, 2013; Copenhagen, Denm ark.
* Use of cefovecin will increase the prevalence of MRSP in dogs
and cats. True or False
*FALSE
*
Fadok VA et al. Clinician’s Brief, 2015.
1610/19/18
*
First Time Treatment Success Evaluations Across Populations of Dogs
Date Data Source Type of Study Population % of Dogs
Cefovecin for Treating Prospective
2008
Canine Skin Infections 1 N=235
Pivotal Study 86%
86%
CAPNA Client Retrospective
2013
Acceptance Trial 2 N=308
G eneral Practice 96%
Convenia: G ive A Dog A Retrospective
2013-2014
Shot Shelter Program 2 N=40
Shelter 90%
Prospective VCA G eneral Practices
2014-2015 Speed of Response 2
N=46 Acute Moist Derm atitis
93.5%
Data Analysis of
Convenia: You Call the
2014-2015
Shots Reim bursem ent 2
Reim bursem ent All 89.9%
Program N=11,519
1. Efficacy and safety of cefovecin in treating bacterial folliculitis, abscesses, or infected w ounds in dogs. Six R, Cherni J, Chesebrough R,
et al. JAVM A2 33:433-439, 2008.
2. Zoetis Data on file, 2016.
3. Wright et al. First treatm ent success w ith injectable cefovecin sodium in dogs for superficial pyoderm a, w ounds, and abscesses in
different dog populations. ISPOR 21 2016
*Why I use Convenia®
Levels persistently above MIC in tissue for at least 2 weeks
Free Cefovecin Concentrations in Plasma vs. Transudate (Tissue Cage Studies)
Stegemann MR et al. 2006. J Vet Pharmacol Ther 29:501.
* Why I prefer Simplicef to cephalexin
Tissue ½ life of cefpodoxime longer than that for cephalexin
a Cephalexin- Cephalexin- Cefpodoxime- Cefpodoxime-
Plasma Tissue Plasma Tissue
Cmax (ug/ml) 31.5 16.3 33 4.3
AUC (ug/ml) 155.6 878 282 575
T ½ (hrs) 4.7 3.2 5.7 10.4
Cephalexin 25 mg/kg; cefpodoxime 9.6 mg/kg
Papich MG et al. 2010. Am J Vet Res 71:1484.
1710/19/18
*
*
When pyodermas no longer respond
When to suspect MRS?
• If there is < 50% improvement in 2
weeks
• If disease initially responds to
antibiotic but lesions recur during
therapy
• Culture and sensitivity required
• Empirical selection of antimicrobials
is contraindicated
• Be sure your lab tells you the species
the Staphylococcus.
• Including coag neg strains
Morris DO et al. Vet Dermatol 2017; 28:304
1810/19/18
*What are the risk factors for MRS?
• Using many different classes of
antibiotics
• Previous antibiotic treatment within
the last 6-12 months
• Use of antibiotics without veterinary
supervision
• Veterinary visits
MRS in biofilm
Shutterstock Royalty Free • Hospitalization and/or surgery
• Exposure to another patient or
Zur G et al. Vet Dermatol 2016; 27:468 human with MRS
Hensel N et al. Vet Dermatol 2016; 27:72
Lehner G et al. Vet Microbiol 2014: 168:154
vanDuijkeren E et al. J Antimicrob Chemother 2011; 66:2705
Lloyd D. Schweiz Arch Tierheilkd 2010; 152:131
*
*Few are Staphyococcus aureus (MRSA).
*Most are methicillin resistant S.
pseudintermedius or S. schleiferi (MRSP or
MRSS).
*Methicillin resistance does not make the bacteria
more virulent or more contagious, just harder to
get rid of.
Methicillin Resistant Staph pseudintermedius
Sensitive Only to Doxycycline and Amikacin
This is NOT MRSA it is MRSP
1910/19/18
*
* If you can use clindamycin, potentiated sulfas, by all
means do so.
* Make sure that the bug is sensitive to erythromycin
and azithromycin too (clindamycin-inducible
resistance gene)
* If you use doxycycline, check the MIC: If it is greater
than 0.5 to 1 ug/ml, likely won’t work
* Lab needs to use updated CLSI standards
* Often left with the wicked three
* Chloramphenicol: 30-50 mg/kg q 8 hrs
* Amikacin: 15 mg/kg subq q 24 hrs
* Rifampin: 5-10 mg/kg/day
Morris DO et al. Vet Dermatol 2017; 28:304
Worth a try if reported sensitive
Resistance might develop during treatment
Culture and sensitivity required to pick correct
one
Use a veterinary fluoroquinolone
*
Morris DO et al. Vet Dermatol 2017; 28:304
*
There are no reasonable choices for systemic
therapy
Vancomycin?
Reserved for life-threatening infections only
Canine pyoderma is not life threatening for most dogs
Linezolid?
Controversial--should this be used in vet med?
Expense
To avoid the use of risky antibiotics like amikacin or
rifampin
2010/19/18
Does Daily Bathing Resolve
Pyoderma/Yeast Dermatitis?
Chlorhexidine/miconazole bath daily for 6 weeks
Pyoderma score
Dogs with methicillin sensitive
S. pseudintermedius treated with
Amoxicillin clavulanate
Dogs with methicillin resistant
S. pseudintermedius treated topically
2110/19/18
*An antibiotic that works this time may not work next
time
*Must culture each subsequent infection
*Prevention!
*Regular bathing
*Consider the use of barrier repair lipids
*Treat the underlying cause
*
*
*
Staphage Lysate
DeBoer et al. Am J Vet Res 1990;
51:636
What’s on the horizon?
Staphylococcal vaccine?
Abouelkhair et al. Development of a
vaccine to treat Staphylococcus
pseudintermedius infections in dogs.
2018. NAVDF abstract
2210/19/18
Should we take a break from systemic antibiotics?
Reduce selection pressure
Avoid the use of fluoroquinolones unless you have a
gram negative infection or culture/sensitivity results.
Keep abreast of guidelines
Consider compliance when choosing antibiotics
Bathing is a critical component
Get at that underlying cause early!
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